Optimum Imaging Strategies for Advanced Prostate Cancer

Publication Date: January 15, 2020
Last Updated: March 17, 2022



Prostate cancer is the most common non-dermatologic cancer in men. In 2019, it was estimated that there would be 174,650 new cases in the United States, and in spite of advances in diagnosis and treatment, an estimated 31,620 deaths would occur.

Prostate cancer poses unique challenges:
  • A distinct clinical disease state characterized by an elevated serum prostate specific antigen (PSA) consistent with recurrent disease without findings of metastases on historically conventional imaging studies
  • Difficulty in monitoring patients with metastatic bone disease due to the poor test characteristics of conventional bone imaging
  • Increasing evidence for
    • Local salvage therapy
    • Metastasis-directed therapy
    • Increasingly effective early systemic therapies

The predilection for prostate cancer to metastasize to bone and lymph nodes requires both bone and soft tissue imaging techniques.

Advances in nuclear medicine and molecular imaging are poised to reinvent the way in which we diagnose, stage and monitor response to therapy in patients with prostate cancer.



Imaging is recommended for all patients with advanced prostate cancer. (See Recommendations 4.1-11 for specific details according to clinical scenario) ( EB , H , B , M )

One or more of the following imaging modalities should be used for patients with advanced prostate cancer: conventional imaging (defined as computed tomography, bone scan and/or prostate MRI), and/or next generation imaging (NGI) (PET, PET/CT, PET/MRI, whole body MRI), according to clinical scenario ( EB , H , B , M )

It is recommended when choosing an imaging modality that disease states and clinical scenarios as described are taken into consideration, since the imaging modality may guide treatment or change clinical treatment decisions. ( EB , H , B , M )

Newly Diagnosed Clinically High-Risk/Very High-Risk Localized Prostate Cancer

Conventional imaging negative

When conventional imaging is negative, next generation imaging (NGI) may be offered to patients for potential detection of sites of disease amenable for treatment, although prospective data are limited. ( IC , Ins , H , )

Conventional imaging suspicious/equivocal

When conventional imaging is suspicious or equivocal, NGI may be offered to patients for clarification of equivocal findings or detection of additional sites of disease which could potentially alter management, although prospective data are limited. ( IC , Ins , H , W )

Rising PSA after prostatectomy and negative conventional imaging (either initial PSA undetectable with subsequent rise or PSA never nadirs to undetectable)

For men that are not candidates or are unwilling to receive salvage local or regional therapy, additional NGI should not be offered. ( IC , Ins , H , W )
For men for whom salvage radiotherapy is contemplated, NGI should be offered (PSMA imaging (where available), C-11 choline or F-18 fluciclovine PET/CT or PET/MRI, whole body MRI and/or F-18 NaF PET/CT) since they have superior disease detection performance characteristics and may alter patient management. ( EB , H , B , S )

Rising PSA after radiotherapy and negative conventional imaging

For men in whom salvage local or regional therapy is not planned or is inappropriate, there is little evidence that NGI will alter treatment or prognosis. The role of NGI in this scenario is unclear and should not be offered, except in the context of an IRB (Institutional Review Board) approved clinical trial. ( IC , Ins , H , M )
For men for whom salvage local or regional therapy (e.g., salvage prostatectomy, salvage ablative therapy, or salvage lymphadenectomy) is contemplated, there is evidence supporting NGI for detection of local and/or distant sites of disease. Findings on NGI could guide management in this setting (e.g., salvage local, systemic or targeted treatment of metastatic disease, combined local and metastatic therapy). PSMA imaging (where available), C-11 choline or F-18 fluciclovine PET/CT or PET/MRI, whole body MRI and/or F-18 NaF PET/CT have superior disease detection performance characteristics compared to conventional imaging and alter patient management, although data are limited. ( EB , H , H , M )

Metastatic prostate cancer at initial diagnosis or after initial treatment, hormone sensitive

In the initial evaluation of men presenting with hormone-sensitive disease with demonstrable metastatic disease on conventional imaging, there is a potential role for NGI to clarify the burden of disease and potentially shift the treatment intent from multimodality management of oligometastatic disease to systemic anti-cancer therapy alone or in combination with targeted therapy for palliative purposes, but prospective data are limited. ( IC , Ins , H , M )

Non-metastatic CRPC (nmCRCP)

For men with nmCRPC, NGI can be offered only if a change in the clinical care is contemplated. Assuming patients have received or are ineligible for local salvage treatment options, NGI may clarify the presence or absence of metastatic disease, but the data on detection capabilities of NGI in this setting and impact on management are limited. ( IC , Ins , H , W )

Metastatic CRPC

PSA progression

PSA progression alone for men on treatment for metastatic CRPC should not be the sole reason to change therapy. Conventional imaging can be utilized for initial evaluation of PSA progression and should be continued to facilitate changes/comparisons and serially to assess for development of radiographic progression. ( IC , Ins , B , M )
The use of NGI in this cohort is unclear, with a paucity of prospective data. When a change in clinical care is contemplated, in an individualized manner, and there is a high clinical suspicion of subclinical metastasis despite negative conventional imaging, the use of NGI could be contemplated, especially in the setting of a clinical trial. (IC, U, W, Ins)

Radiographic progression on conventional imaging

In men with metastatic CRPC with clear evidence of radiographic progression on conventional imaging while on systemic therapy, NGI should not be routinely offered. NGI may play a role if performed at baseline to facilitate comparison of imaging findings/extent of progression of disease. (IC, U, M, Ins)

Figure 1. Imaging Algorithm for High/Very High-Risk Disease at Initial Presentation (per National Comprehensive Cancer Network [NCCN])

Figure 2. Imaging Algorithm for Patients with Rising Prostate-Specific Antigen (PSA) After Local Treatment

Recommendation Grading


  • CRPC: Castration-resistant Prostate Cancer
  • MRI: Magnetic Resonance Imaging
  • NCCN: National Comprehensive Cancer Network
  • PET: Positron Emission Tomography
  • PSA: Prostate-specific Antigen
  • PSMA: Prostate-specific Membrane Antigen
  • bs: Bone Scintigraphy
  • ct: Computerized Tomography
  • ct: Computerized Tomography
  • mets: Metastatic Disease
  • mets: Metastatic Disease
  • mpmri: Multiparametric Magnetic Resonance Imaging
  • ngi: Next Generation Imaging
  • wb: Whole Body


This pocket guide is derived from recommendations in the American Society of Clinical Oncology Guideline. This resource is a practice tool based on ASCO® practice guidelines and is not intended to substitute for the independent professional judgment of the treating physician. Practice guidelines do not account for individual variation among patients. This pocket guide does not purport to suggest any particular course of medical treatment. Use of the practice guidelines and this resource are voluntary. The practice guidelines and additional information are available at www.asco.org/supportive-care-guidelines. Copyright © 2021 by American Society of Clinical Oncology. All rights reserved.


CPT Codes

Code Descriptor
55700 Biopsy
72193 Computed tomography, pelvis; with contrast material(s)
55865 Exposure of prostate
72192 Computed tomography, pelvis; without contrast material
72195 Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s)
77401 Radiation treatment delivery
55862 Exposure of prostate
55706 Biopsies
78813 Positron emission tomography (PET) imaging; whole body
72194 Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections
81313 PCA3/KLK3 (prostate cancer antigen 3 [non-protein coding]/kallikrein-related peptidase 3 [prostate specific antigen]) ratio (eg
81539 Oncology (high-grade prostate cancer), biochemical assay of four proteins (Total PSA, Free PSA, Intact PSA, and human kallikrein-2 [hK2]), utilizing plasma or serum, prognostic algorithm reported as a probability score
55860 Exposure of prostate
72197 Magnetic resonance (eg, proton) imaging, pelvis; with contrast material(s), followed by contrast material(s) and further sequences
84153 Prostate specific antigen (PSA); total
55705 Biopsy
84152 Prostate specific antigen (PSA); complexed (direct measurement)
72196 Magnetic resonance (eg, proton) imaging, pelvis; with contrast material(s)
77402 Radiation treatment delivery
77075 Radiologic examination, osseous survey; complete (axial and appendicular skeleton)
77385 Intensity modulated radiation treatment delivery (IMRT)
72191 Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing
84154 Prostate specific antigen (PSA); free
77074 Radiologic examination, osseous survey; limited (eg, for metastases)

ICD-10 Codes

Code Descriptor Documentation Concepts Quality/Performance
Z191 Hormone sensitive malignancy status